"Variation in excess cases of adverse events amenable to health care: low value care with budgetary impact" Comendeiro-Malloe, Ridao-López M, Martínez-Lizaga N, Angulo-Pueyo E, García-Armesto S, Bernal-Delgado E on behalf of the Atlas VPM team

1. Varia%on
in
excess
cases
of
adverse
events
amenable
to
health
care:
low
value
care
with
budgetary
impact
Comendeiro-­‐Malloe,
Ridao-­‐López
M,
Mar4nez-­‐Lizaga
N,
Angulo-­‐Pueyo
E,
García-­‐Armesto
S,
Bernal-­‐Delgado
E
on
behalf
of
the
Atlas
VPM
team

2. This
is
Micaela

3. BACKGROUND
METHODS
RESULTS
QUESTIONS
FOR
DEBATE

4. BACKGROUND
Lower-­‐value
care
(definiTon
from
paper
in
Berlin
Spanish
cases
(from
PSI
paper)
Rivard
paper
(copy
&
past)

5. DEFINITION
OF
VALUE
Underuse
of
effecTve
intervenTons
EffecTve
intervenTons
performed
on
non-­‐eligible
paTents
IntervenTons
with
a
more
cost-­‐effecTve
alternaTve
EssenTally
ineffecTve
intervenTons
Low
quality
intervenTons
Unsafe
intervenTons

6. PSI
0.5
7.7
1.8
4.9
17.3
EB:
0.19
[CI:0.12;0.28]

7. Rivard

8. AIM
EsTmate
the
excess-­‐cost
ahributable
to
the
appearance
of
postoperaTve
PTE
and/or
DVT

9. METHODS
SETTING
VARIABLES
MAIN
&
SECONDARY
ENDPOINTS
ANALYSIS

10. Popula%on
and
seNng
• All
paTents
over
17,
undergoing
surgery
in
2009
or
2010:
1.1
million
paTents
– CondiToned
to
paTents
who
survived
– Excluded
PTE/DVT
as
the
cause
of
admission
– Excluded
stays
below
2
days
– Excluded
admissions
within
MDC14:
pregnancy,
delivery
and
puerperium
• 50
hospitals
with
the
largest
surgical
acTvity
– 56%
of
the
surgical
acTvity
in
Spain

11. Variables
• Excess-­‐cost
– Excess
length
of
stay
• Main
predictor
for
excess-­‐cost
– Having
or
not
postoperaTve
PTE
and/or
DVT
• AlternaTve
predictors
for
excess-­‐cost
– Age
– Sex
– ComorbidiTes
– Hospital
of
treatment

12. Main
&
secondary
endpoints
• Excess-­‐LOS
per
hospital
– Average
– CondiToned
to
those
exposed
to
the
risk
of
having
AE
• Excess-­‐cost
per
hospital

13. Analysis
• StraTfied-­‐descripTve
• MulTlevel
log-­‐lineal
-­‐
average
effect
• Kernel
matching
to
determine
average
LOS-­‐excess,
condiToned
to
the
risk
of
adverse
event

14. Risk
score
PaTents
never
have
PTE/DVT
PaTents
always
have
PTE/DVT
Risk
of
PTE/DVT
Subpop
of
paTents
with
a
priori
higher
average-­‐risk
Subpop
of
paTents
with
a
priori
lower
average-­‐risk

15. Matching
PaTents
never
have
PTE/DVT
PaTents
always
have
PTE/DVT
Risk
of
PTE/DVT
Subpop
of
paTents
with
a
priori
higher
average-­‐risk
Subpop
of
paTents
with
a
priori
lower
average-­‐risk

16.
LOS
No
Event
average
(s.d.)
LOS
event
average
(s.d.)
Differential*
n=1.064.836
n=7.777
PSI
12
or
Adverse
Event
Overall
cases
10,48
(13,89)
22,39
(24,87)
11,9
For
each
of
the
characteristics
of
the
episodes
Age
From
18
to
39
7,6
(12,94)
30,24
(34,71)
22,64
From
40
to
64
9,7
(14,29)
24,44
(28,02)
14,74
65
or
older
11,8
(13,69)
20,74
(21,91)
8,94
Gender
Mail
11,07
(14,63)
22,86
(25,70)
11,79
Female
9,8
(12,96)
21,83
(23,85)
12,03
Comorbidities
(Elixhauser)
Pulmonary
circulatory
disease
15,54
(16,60)
23,56
(25,17)
8,02
Paralysis
22,02
(30,68)
40,73
(48,59)
18,71
Lymphoma
14,54
(15,72)
22,61
(25,71)
8,07
Cancer
with
metastasis
16,75
(16,39)
18,57
(16,52)
1,82
Metastasis
without
solid
tumour
11,99
(14,50)
17,41
(14,54)
5,42
Coagulopathies
18,36
(21,30)
28,62
(29,43)
10,26
Weight
loss
25,36
(26,82)
34,76
(31,27)
9,40
LOS
in
those
with
and
without
PTE/DVT

17. Hospital)Lenght)of)Stay)
Model1))
Hospital)effect)
(empty)model))
Model2))
Hospital)effect)and)
Adverse)Event)
Model)3)
RiskAadjusted)by)
the)morbidity)
characteristics)of)
the)episodes)and)
hospital)
Episode(characteristics))
(β"coeff,"95%"CI)"
"
" " "
Constant) 7,37"(7,16"""7,59)" 7,33"(7,12"""7,55)" 3,83"(3,63"""3,90)"
Psi12(PTE"post"o"TVP)" " 2,03"(1,99"""2,07)" 1,40)(1,38)))1,43))
Age) " " "
From"18"to"39"years" " " AAA"
From"40"to"64"years" " " 0,99"(0,86"""1,00)"
65"or"older" " " 1,04"(1,40"""1,57)"
Gender) " " "
Mail" " " AAA"
Female" " " 0,99"(0,99"""1,00)""
Comorbidity)(Elixhauser)" " " "
Paralysis" " " 1,32"(1,30"""1,33)"
Lymphoma" " " 2,67"(1,08"""1,13)"
Metastatic"Cancer" " " 1,36"(1,35"""1,38)"
Coagulopathies" " " 1,12"(1,10"""1,14)"
Weight"loss" " " 1,58"(1,56"""1,60)"
Amount)of)secondary)
diagnosis)" " " 1,11"(1,10"""1,11)"
(
Hospital(effect(
" " "
Variance"of"level"hospital"(SE)" 0,11" 0,11" 0,13"
Average
excess
LOS

18. Model
Excess
LOS*
Average
excess
LOS
(log-­‐linear)
1.40
Average
excess
LOS
conditioned
to
risk
(overall)
1.75
Average
excess
LOS
conditioned
to
risk
(within
hospital)
1.74
Min
1.2
Max
2.4
EQ
1.7
IQ
1.3
*
Basal
Hospital
length
of
stay:
3,83
days
*Peiró-­‐Moreno
S,
García-­‐Petit
J,
Bernal-­‐Delagado
E,
Ridao-­‐López
M,
Librero-­‐López
J.
“El
gasto
hospitalario
poblacional,
variaciones
geográbicas
y
factores
determinantes”.
Presupuesto
y
gasto
público
2007;49:193-­‐209
Excess
LOS
condi%oned
to
same
risk

19. QUESTIONS
FOR
DEBATE
RISK
MATCHING
IS
JUST
BUILT
ON
OBSERVABLE
FACTORS
TIME-­‐DEPENDENT
BIAS
MISS-­‐CLASSIFICATION
OF
THE
EVENT

20. JUST
OBSERVABLE
• Are
we
missing
some
variables
at
paTent-­‐level
that
could
determine
differences
in
risk,
beyond
the
already
considered
in
the
risk
score?
• Since
the
esTmaTon
of
the
risk-­‐score
has
considered
unobservable
hospital-­‐specific
variables
(mu),
and
the
event
has
been
defined
as
a
paTent
safety
event
(likely
ahributable
to
hospital
care)
–
are
we
miTgaTng
the
bias?

21. Time-­‐dependent
bias?
In
the
opposite
sense

22. Miss-­‐classifica%on
of
events
How
to
increase
PPV?

23. IMPACT

24. Alarm
performance
Alert
performance
Average
performance
Good
performance
Excellent
performance
Flagging
hospitals
beyond
a
threshold
VariaTon
in
the
adjusted-­‐incidence
of
PTE/DVT

25. Performance
relative
position
in
terms
of
ATET
Hospitals
Episodes
AE-­‐PSI12
Cost
differential
Alarm/Alert
(%
total)
10
(20%)
229,792
(24.6%)
1,736
(22.3%)
€
19,705,221.16
(29%)
Average
(%
total)
29
(58%)
515,595
(55.1%)
4,168
(53.6%)
€
36,010,872.96
(53%)
Good/Excellent
(%
total)
11
(22%)
190,015
(20.3%)
1,873
(24.1%)
€
12,264,628.15
(18%)
Total
50
(100%)
935,402
(100%)
7,777
(100%)
€
67,980,722.3
(100%)
Impact
on
costs
*Peiró-­‐Moreno
S,
García-­‐Petit
J,
Bernal-­‐Delagado
E,
Ridao-­‐López
M,
Librero-­‐López
J.
“El
gasto
hospitalario
poblacional,
variaciones
geográbicas
y
factores
determinantes”.
Presupuesto
y
gasto
público
2007;49:193-­‐209

26. 8.4
4,0
5,0
6,0
7,0
8,0
9,0
10,0
3,0
5,0
7,0
9,0
11,0
13,0
15,0
17,0
19,0
Risk
adjusted
hospital
incidence
of
adverse
events*1,000
surgeries
ATET
(extra
days)
after
TVP
(psi12)
Quadrant
I
Quadrant
II
Quadrant
III
Quadrant
IV
6.7
8.4
Concilia%ng
safety
and
costs
Incidence
of
Adverse
Events
vs.
Average
effect
on
the
exposed

27. PTE
&
DVT
aWer
surgery
across
countries
1,43 7,55 0,87 4,36 1,87

28. ANNEX:
MODEL
SPECIFICATIONS

29. Log-­‐linear
specifica%on

30. Risk-­‐score
matching
specifica%on